1

Medical Education and Training Summit Day 1

An Overview of the NT Medical Education and Training Review Dr Janie Smith – Director RhED Consulting Pty Ltd THE BRIEF

• Map current providers and activities: • Provide an analysis of the efficiency, effectiveness and appropriateness of current

education and training programs: • Recommend options for a more cohesive and coordinated approach: • Key roles and responsibilities: • Development of clearer pathways between hospital and community training institutions.

WHAT WE DID – METHOD

• Literature review • Mapped the providers – 37 • 106 interviews stakeholders • 2 focus groups • 3 case studies • Survey 14 feeder universities – students • Strategy workshop • Written report, recommendations. • 9 months ago………

NT CONTEXT

• Small population • Dispersed geographically • Highest Indigenous • Exceptionally high CD • Small medical workforce • Small specialty silos • 5 hospitals • High IMG numbers • Attractive to students • No medical school • High interprofessional needs • Everyone knows each other – many hats • Under resourced

2

WHAT DID WE FIND?

• Passionate committed workforce – 440 • Challenging multicultural workplace • Fascinating medicine • Good educational experiences • Some fantastic teachers • •Tsunami’ of medical students • Real opportunities for innovation • Its different

WHAT WORKS?

Top 5 strengths of current NT medical education & training

0 10 20 30 40 50 60

Fascinatingmedicine

Good educationalexperiences

Fantastic teachers

NTGPE

Other

Number of responses (n=126) in total

3

WHAT DID WE FIND? • Structure built for NSW • 37+ providers for 440 doctors (excl GPs+AMS) • Disciplinary Silos • Poor coordination information flow • No existing hospital accrediting structure • Affecting intern training + retention • Poor IMG support – based mainstream • Significant recruitment and retention issues • Focus on workforce not populations needs • No clear leader

WHO IS THE LEADER?

WHAT STUDENT ISSUES DID WE FIND?

• Multiple providers for very small numbers • 2 clinical schools • 30ish students; 38 staff; 4 funding streams; • + UDRH – CRH • 14 feeder universities co-ordinated by NTGPE • 370 students, 6 funding streams • More demand vs supply supervision • Placements very confusing + other disciplines • Imprint is like a watermark • Flinders determine the structure!

Who is ultimately responsible for medical education and training in the NT?

0 5 10 15

1

Number of responses (n=40)

No oneNTDH&CSNTGPE NTCS/RCSOther

4

PGY1-2 WHAT DID WE FIND?

• No PGMEC for 2 yrs • Provisional accreditation RDH • 25 recommendations to implement by Nov 07 • No DCT • Issues • Poor quality and coordination of training • Lack of release time for training • Insufficient training budget • Poor focus on education vs recruitment • Dissatisfaction re pay and conditions • Junior doctor curriculum – poor understanding • No structure IMG support or system – 33%

VOCATIONAL TRAINING

• 9 generalist and specialist colleges • All separate accreditation requirements • Small numbers of registrars • Largely hospital based 3-20 av 10 • GP registrars 47 • Supervision – every layer teaches every layer – burn out consultants • Some good educational activity – RDH-ED+ NTGPE • Real opportunities for the generalist spec and innovation and interprofessional learning

e.g. cross cultural

CPD WHAT DID WE FIND? • 3 Divisions GP groups! • 4 GP / rural medicine groups • 7 specialist colleges • + Govt, unis, AMSs + pharmaceutical companies • Some good educational activity • Could be more innovative and cross disciplinary

5

THE GAPS

WHAT DOESN'T WORK?

Where are the gaps? (n=55)

6

3

11

12

22

0 5 10 15 20 25

Other

Can't complete VT pathway NT

Access training + remote

IMG support + training

PGY1+2 training + support

number of responses

The 7 greatest barriers to cohesive training

0 5 10 15 20 25 30

Workforce no's, support & resources

Lack of coordination of training

Low priority of education & poor vision

Distance

Funding

The silo mentality

Others

Number of responses (n=102)

6

DUPLICATION? WHAT NEEDS TO CHANGE?

Where is the duplication? (n=43)

0 5 10 15 20

Other / Don’t know

Post graduate sector

Cultural awareness

CPD

Student placements

number of responses

Top 7 priorities for change (n-72)

7

7

8

15

18

22

26

0 5 10 15 20 25 30

Incr

ease

d f

undin

gD

edic

ated

educa

tion

pro

vider

& r

ole

s

Percentages

7

SPOTLIGHTING AREAS OF RESPONSIBILITY OPPORTUNITIES FOR INNOVATION

• Model that recognises difference and builds on the existing strengths • Remote, Indigenous, infectious + tropical diseases • Alternative medical school model • Hosp Generalist specialist • Interprofessional learning – cross cultural • Model that meets populations health care needs • Placements that value add- IPL • Links with SE Asia • Training pathway for IMGs • A model that could lead Australia in innovation

IN 2018

• Where will you be? • What will you be doing? • What we do today will leave the footprint for those undertaking our roles in 2018 …lets

focus on the best structure for them

8

NT Medical Student Education Dr Michael Lowe - Clinical Dean, NT Clinical School, Flinders University

CHAOS OR COMPLEXITY? - THE RHED PERSPECTIVE:

AND COMMON CHALLENGES…

• Students to have NT & Aboriginal Health experience • Students to return to intern and practice in the NT • Enhance job satisfaction & retention of staff

• Good teaching recruits good students

NTCS NTGPE

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AND COMMON CHALLENGES… • Increasing need for student placements • Teaching infrastructure • Clinical Supervisors • Rural and remote health

• Changing patient care needs TWO ORGANISATIONS: COMPLEMENTARY PROGRAMS

Flinders Y3 (16 full yr): JCU Y6 (8 full yr): RDH/WA 6/12 in RDH, 6/12 in community /rural Students from across Australia

JCU Yr 5 (8 full yr): RUSC (~110 places): RDH/GP rural/remote plcmt 4-6 wks (incl

elective placements)

Flinders Y4 and electives (200 places) John Flynn (~60 places): RDH/ASH 6 wks rural community 2 wk/yr for entire

course

THE AUSTRALIAN SITUATION AUSTRALIAN MEDICAL GRADUATES

NTCS NTGPE

↑ # of doctors

↓ # of student supervisors

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HOW THE NTCS IS ADDRESSING THIS CHALLENGE

• Expanding teaching settings • Community (including Super clinic) • Private sector • Rural/remote (including Gove) • Coordination across different levels of teaching

• Greater emphasis upon multidisciplinary teaching/learning

NEW NTCS EDUCATIONAL MODELS

• Rural Clinical School o GP-based o Katherine/ Gove / Alice o 8-16 NTCS student placements per year (1 semester each) o Commonwealth funded

• CBME o GP based - Darwin urban o C4 program – community based health providers (e.g., Family Planning, skin clinic,

diabetes educator)

“The most rewarding experience [of the CBME program] has been being able to take responsibility for my own patients in the GP clinic. I have found procedures such as suturing and corneal foreign body removal interesting and enjoyable. The opportunity to visit other providers in the community and gain a holistic understanding of continuity of care has been invaluable”.

CBME student, 2008

ABORIGINAL HEALTH PLACEMENTS • Laynhapuy Homelands • AMSs • Tiwi Islands

• Dedicated stream of curriculum

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THE FUTURE - THE MEDICAL WORKFORCE PIPELINE LEAKS IN THE MEDICAL WORKFORCE PIPELINE

(Where/why losing potential NT health workforce?)

School Leaver

Medical School

Pre-clinical years Flinders or JCU

Clinical years NTCS (HBME, CBME, RCS)

Intern year (+/- PVGPPP)

RMO years (+/- PVGPPP)

Specialty training

Practicing NT doctor!

Undergrad deg.

School Leaver

Medical School

Pre-clinical years Flinders or JCU

Clinical years NTCS (HBME, CBME, RCS)

Intern year (+/- PVGPPP)

RMO years(+/- PVGPPP)

Specialty training

Practicing NT doctor!

Undergrad deg.

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Apply Acceptable Recruited to NT % NT School Leavers for undergrad med

60 (UMAT)

16

4-6 (JCU)

25%

NT Graduates for Grad entry medicine

25 (GAMSAT)

13

8-10 (Flinders)

62%

NTCS Grads for intern

24

10-14

55%

NTGPE Elective for junior docs

18

7

38%

Intern for PGY2

50%

PGY (N) for PGY (N+1)

50%

13

THE RESULT: MEDICAL WORKFORCE SHORTAGES HOW TO KEEP THEM HERE? THE EVIDENCE SAYS Why they left: “ …Those who moved to the NT as a result of financial incentives or who had strong expectations that working in the NT would be an exciting, novel experience tended to stay for no more than 5 years, often leaving because they found the work environment too stressful.” Why they stayed: “In contrast, those who stayed longer came because they had existing social networks and were familiar with the NT environment…”

NTCS STUDENTS RETURN TO THE NT FOR INTERNSHIP: THE TAKE-HOME MESSAGE:

NSW

NT QLD SA TAS VIC WA O/S Total

not NTCS 24 13 15 217 7 13 15 52 3567% 4% 4% 61% 2% 4% 4% 15%

non quota

9 33 0 11 6 1 4 5 6913% 48% 0% 15% 8% 1% 6% 7%

quota 0 19 2 3 1 0 2 0 270% 70% 8% 12% 4% 0% 8% 0%

Totals 33 65 17 231 14 14 21 57 4527% 14% 4% 51% 3% 3% 5% 13%

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Train doctors from = Keep doctors in the NT the NT, in the NT BLOCKING THE LEAKS IN THE MEDICAL WORKFORCE PIPELINE Full medical training in the NT NT school leavers should be able to train in Medicine in NT:

• B Med Sci CDU ( 1st 2 yrs) • Year 1 and 2 of Flinders course on CDU/Menzies campus (NTCS) • Yrs 3 and 4 with NTCS, with extra students from Flinders and JCU joining them at start of

year 1 and start of final 2 years. • Commitment to collaboration – Flinders/CDU/other partners • Funding • Commonwealth • NTG • Affirmative policies for Indigenous/Territory entry • Any program must place Aboriginal Health at centre

• Curriculum, governance, collaboration. WHAT I WOULD LIKE FROM THIS SUMMIT:

• Commit to training our workforce locally • Include NT Flinders/CDU School –

• Commit to retention of NT workforce and potential NT workforce

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Pre-Vocational Training – The View from the Swamp Dr David Chapman, Acting Director of Clinical Training, Royal Darwin Hospital

INTERESTING TIMES Medical Education & Training Review Medical Education & Training Summit Despite irreverence, flippancy and cynicism, there is a sense of action, anticipation & excitement.

WHO’S WHO & WHAT’S WHAT OF PRE-VOCS

• Post Graduate Year 1 (PGY1) - Interns • PGY2 – 4 Resident Medical Officers (RMO)

• PGY2 – 8 International Medical Graduates (IMGs) in RMO positions

WHERE DO THEY FIT IN THE CONTINUUM? • Interns: 1st year after graduation with conditional registration • 48 weeks of service in an accredited hospital. • Terms in General Medicine and General Surgery + 2 electives • Dedicated training and supervision AND THEN • On successful completion: Full Registration • RMOs and currently not required to participate in formal training and supervision

• May remain “undifferentiated”, or prepare for a specialist training program

THE CHANGING PROFILE OF PRE-VOCATIONAL TRAINEES • Increasingly older, more experienced & in a hurry • Often parents and partners, not partying backpackers • Expecting workplace flexibility • Expecting relevant & professionally delivered training

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WHERE ARE THEY?

The equivalent of a moderately large metropolitan hospital spread over an area equal in size to France, Italy and Spain combined (olé)

WHAT DO WE DO IN PRE-VOCATIONAL TRAINING? • General Training: 1.5 hours across a lunchtime

• Pager protected & “compulsory”

• Clinical scenario based, • Adaptable to the changing needs of the Hospital AND of JMOs.

RDH

ASH

KDH

GDH TCDH

PGY 1

16 8

PGY 2-4

35

14

1

0

0

PGY 2-4 IMG

10

10

PGY >4 IMG

5

4

8

1

1

Totals

66 36 9 1 1

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DIVISIONAL & DEPARTMENTAL TRAINING • Grand Rounds: the theatre of the intellect

• Radiology meetings: fuzzy pictures of peoples’ insides

• The Consultant Round: “The Medical Student Inquisition”

• Teaching on the Run: peripatetic quiz night • See One, Do One, Teach One”: learning by anxiety

• Handover: “grilling the Registrar”

SPECIAL COURSES • Advanced Life Support Courses • National Trauma Centre Short Courses (incl EMST etc)

• Occasional Registrar/Senior RMO Development Courses “bought in” (PDRP)

THE CURRENT LOCAL CONTEXT • An imperative to attract & retain suitable Medical Officers • NT sandwiched between WA & Qld – the Scylla of Salary and the Charybdis of Conditions • Attraction is not just $$ - reputation matters

THE EMERGING LOCAL CONTEXT • Uncertainty in supply of IMGs

• Competition for vocational trainees: a need to “grow our own”

• A renaissance of a learning culture

THE CURRENT & EMERGING NATIONAL CONTEXT

• The “Tsunami”: quality versus quantity?

• Not pick & choose, but compete or capitulate • Taking the Baden Powell approach: “Be Prepared”

• PGY 2 & beyond – the “forgotten ones” o Currently perceived as service providers rather than trainees o Supervision to become more aligned with PGY 1? o Hospital accreditation for PGY 2 & above to come?

• The Australian Curriculum Framework o Exemplifying the spiral curriculum o A shift in emphasis: professionalism o Supervision & assessment: increased rigour

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• International Medical Graduates (IMGs)

o “It isn’t only culture” o Serious supervision

• Early specialisation o Early choice or accelerated training? o The benefits of generalist pre-vocational training o Service or training: apprentice or student?

• Early streaming o Speeding the process or limiting the experience? o How much diversity equals generalist training? o Enabling choice

• Role substitution: “see one, do one…if you’re lucky”

• Models of training:

o Simulation versus “the real thing” o Apprentice versus student

WHAT SHOULD BE OUR VISION? • “The Bees Knees in Medical Education & Training” • To ensure all JMOs have access to a standard of training that enables them to realise their

full potential as Doctors

WHY? • To enable the Territory to provide a cost effective and excellent standard of health care

appropriate to the needs of its population

HOW DO WE GET THERE? - STRATEGIES • Aggressively promote renaissance of a culture of learning and self evaluation = return to the

future • Develop local capacity & fruitful collaboration = excellence, relevance and cost effectiveness • Pursue the widest scope in participation in training = attraction, retention & cost effectiveness • Adopt a network focus = improved health services, greater capacity for managing staffing and

greater opportunities for training

HOW DO WE GET THERE? - TACTICS • Establish an independent Postgraduate Medical Council with a network focus • Articulate forcefully the benefits of balance between service and training: - equally to

government, bureaucracy and practitioners • Local or network – but not both? - • Appoint a Medical Education Team with Director Clinical Training (DCT), Medical Education

Officer (MEO) & Medical Education Assistant (MEA)

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• Appoint Medical Administration staff to facilitate the training vision through recruitment,

placement & rostering • Collaborate in development & delivery of training with the Northern Territory Clinical School &

Rural Clinical School, and Northern Territory General Practice Education • Collaborate in developments with the Postgraduate Medical Council of Queensland (PMCQ)

WHAT MIGHT WE DO, SPECIFICALLY? • Local capacity: PMCQ delivered Train the Trainer courses for Teaching On The Run and

Professional Development of Registrars Program • Locate that capacity within the consortium of training providers: NTCS, NTRCS, NTGPE, NTC • 5 terms in pre-vocational years (with constrained choice for PGY1), and integrate relieving

into rotations • Plan & provide balanced & guaranteed pathways to vocational training from PGY 1 onwards • Development & marketing of PGPPP placements & pathways to GP training • PGY 1 & 2 rotations through District Hospitals with a supervision & teaching infrastructure in

parallel with Medical Student and GP Registrar placements • Network recruitment & placement independent of Hospital administrations • Electronic tracking of JMO careers • Professional Training Allowances paid to all JMOs under an agreed performance plan

WHAT ARE THE IMPEDIMENTS? • Staffing • RDH Accreditation report

• Prof Smith’s Med Ed Report

• Department of Medicine Review • Infrastructure:-

o Accommodation o Travel o Training Delivery o Supervision

• Structural change within hospitals o Macro: Patient flow

o Micro: Staffing “buffer” Rostering practices “take” days

ABOVE ALL • An articulated vision and a champion to sustain & realise it • Government & bureaucratic will to fund, fight for and facilitate the vision

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21

International Medical Graduates Dr Alan Ruben – Paediatrician and Public Health Physician Associate Professor, NT Clinical School IMG Training Coordinator, DHCS

RDH Pediatrics’ morning handover, 24 April 2008

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TOP END Royal Darwin Hospital • 49 of 140 (36%) of registrars/RMOs are conditionally registered IMGs, over 50% of the total

staff are IMGs

Katherine and Gove Hospitals • All (100%) the staff at Katherine Hospital are IMGs (although short term locums are often

Australian trained). • Over half the staff at Gove Hospital are IMGs. Royal Darwin Hospital Without IMGs the Emergency Department would lose 60% of its staff, only 1 of the 5 Obstetricians would remain, there would be no Oncology service, there would be no ophthalmology service and no specialist facio-maxillairy or specialist trauma surgeon.

CENTRAL AUSTRALIA Alice Springs Hospital

• Of the 40 specialists, 27 (68%) are IMGs • Of the 27 IMG specialists 9 (33%) are conditionally registered • Of the 59 registrars/RMOs, 21 (36%) are conditionally registered IMGs

• Tennant Creek Hospital

• Mainly staffed by short term junior doctors from interstate • “Inadequately trained and supported”

GENERAL PRACTICE

• 260 GPs in the NT • Unknown number of IMGs • 25 IMG GPs are being mentored through the “5 year scheme” • In this year’s cohort of GP Registrars only 8 of 20 places have been filled, none are IMGs • One IMG is in among 4 new GPRs under a new GPR scheme currently being trialed Sources: Primary Health Care Research and Information Centre - http://www.phcris.org.au General Practice and Primary Health Care NT Northern Territory General Practice Education Ltd

23

CURRENT SYSTEM:

General Registrants: • AMC Part 1 (MCQ) • AMC Part 2 (Clinical) • 12 months minimum of supervised practice Specialist Registrants: • As determined by AMC and Colleges

NEW SYSTEM The AMC allows workplace assessment, whether the employer be a Health Department or General Practice; supervised by the Medical Board and AMC.

1. An eligible IMG can opt to enter the “Competent Authority” Pathway (CA) - workplace assessment

2. Other non-specialist IMGs must remain in the “Standard Pathway” (SP), currently exam based but will become workplace assessment at discretion of the AMC. From 1 July 2008 all new registrants who are not CA eligible must have passed AMC MCQ exam.

3. An IMG can opt to stay in the old system

“COMPETENT AUTHORITY” PATHWAY Eligibility restricted to doctors who are unconditionally registered in the USA, UK, NZ, Canada and Ireland They must apply for a Certificate of Advanced Standing from the AMC. The criteria are: • A primary medical qualification or pass in the licensing exam in one • of those countries, and • At least 12 months supervised practice in an accredited hospital

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“The Competent Authority pathway is a workplace based assessment of their adjustment to the Australian health system, not a clinical skills assessment, as clinical skill has already been assessed by the original Competent Authority”

“STANDARD” PATHWAY Currently Examination based with a minimum of 12 months supervised practice

Will change to workplace based assessment, after completion of AMC1, when AMC completes standards and accreditation procedures

From 1 July 2008 all new IMGs who want to participate in the ‘Standard Pathway’ will have to have passed the AMC Part 1 before they can be conditionally registered/employed.

This is the case for all Australian States and Territories

STEPS IN NEW PATHWAYS 1. (Pre-employment Clinical Interview) 2. Orientation 3. Induction 4. Supervision 5. Assessment 6. Remediation 7. Reporting 8. Registration

25

Alan Ruben NTCS (DHCS) Jill Huck HPLA DCTs David Chapman (RDH) Paul Helliwell (ASH) Tony Watson (KDH) Tamsin Cockayne (GDH) Colin Smith (GDH) Fiona Harley (RDH)

TO DATE, IN DHCS HOSPITALS: • Interviewed 70 IMGs employed by DHCS across the NT • Trained 43 Specialists (including 15 GPs) in IMG assessment with another session this week

in Alice Springs, thereafter training sessions as required. • Enrolling 31 eligible IMGs in Competent Authority Pathway • Ready for Standard Pathway when AMC allows • Organising AMC MCQ tutorials to commence in June • Conducting AMC clinical exam preparation workshop in June

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TO DATE, IN GENERAL PRACTICE:

• Preparations for CA pathway not commenced • 5 year scheme is continuing. • GPs have been trained in IMG assessment as per previous slide. • Introduction of CA pathways are an employer responsibility • NTGPE has run two clinical bridging courses, one each in 2007 and 2008, 25 participants

from hospitals and General Practice, 10 have sat the AMC clinical exam and all passed.

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General Practice Vocational Training Professor Michael Kidd Professor of General Practice, The University of Sydney Past President, The Royal Australian College of General Practitioners GENERAL PRACTICE VOCATIONAL TRAINING • Largest specialty medical training program in Australia • 600 registrars entering training each year • 56 registrars currently with NTGPE • Registrars enroll in the Australian General Practice Training (AGPT) Program • Coordinated by the Australian Government’s General Practice Education and Training

2008 • Now two vocational recognition qualifications offered to all registrars enrolled in AGPT

program o FRACGP o FACRRM

• April 2007, Australian Government amended the Health Insurance regulations to also recognise Fellows of ACRRM as general practitioners under Medicare

• GP registrars can choose to train towards FRACGP or FACRRM or both • Registrars training towards FRACGP can also undertake the RACGP Fellowship of Advanced

Rural General Practice as an additional rural qualification • Training based on the curriculum prescribed by the RACGP and by the ACRRM • Require at least one year of hospital experience before commencing training • Able to apply for AGPT in intern year • Registrars select to train in the general pathway or the rural training pathway • Applicants affected by the “10 year moratorium” are required to join the rural pathway

TRAINING TOWARDS FRACGP • YEAR 1: Hospital term • YEAR 2: GP terms • YEAR 3: GP terms and sit FRACGP examination • YEAR 4: Optional extra year of Advanced Rural Training leading to RACGP Fellowship in

Advanced Rural General Practice

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TRAINING TOWARDS FACRRM • YEAR 1: Core clinical training (hospital) • YEAR 2: Primary Rural and Remote Training • YEAR 3: Primary Rural and Remote Training • YEAR 4: Rural Specialised Training

• Assessment across all four years leading to award of FACRRM • General practice training is coordinated through regional training providers around Australia • The regional training provider for the NT is NT General Practice Education (NTGPE) • NTGPE was established in 2002 by consortium of partners including Flinders University,

Charles Darwin University, GP Divisions of NT, Aboriginal Medical Services Alliance NT, ACRRM and RACGP

• NTGPE has responsibility for: o Community based primary care placements of medical students from across Australia

(up to 170/year through RUSC and 61 with JFSS) o Prevocational General Practice Placement Program (24/annum) o Vocational training of GP registrars (up to 20 new GP registrars/annum) o CPD for GPs and IMGs o Cultural awareness training

REMOTE VOCATIONAL TRAINING SCHEME • Separate GP training scheme, run in partnership by a company established by ACRRM and

RACGP and funded by Australian Government • Training for doctors already working in remote locations who wish to train to attain the

FACRRM and the FRACGP • Supervision is provided remotely • Suitable model for further consideration in the NT, especially for some IMGs

DON’T DISMISS THE IMPACT OF SHORT TERM COMMUNITY PLACEMENTS • Over 600 medical students from The University of Sydney have taken part in clinical

placements and as John Flynn Scholars in the NT over the past 15 years • All have described the remarkable experience • This training does have an impact • Many have returned as interns and/or registrars • Many have returned as qualified GPs either full time or as locums

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Producing Specialists for the North Assoc Professor Richard Murray Dean of Medicine, James Cook University OVERVIEW • The northern Australian context • Generalism vs subspecialisation and the needs of regional Australia • The specialist link to the regional pipeline • Intellectual content of northern specialities

• The research, workforce & quality nexus

Population 949,819 ~1/3rd of total OR/R&R pop 138,201 Indigenous pop (14%, 30% national total)

Darwin (105,991)

Cairns (127,438)

Mount Isa

Atherton

Brisbane

Sydney

Melbourne

Adelaide

Perth Broome Port Headland

Rockhampton (58,749)

Alice Springs

Northern Territory (192,898; 53,490 Ind)

Kimberley & Pilbara (70,299; 17,957 Ind)

Emerald

Mackay (84,890)

TropicalQLD 688,525 63,269 Ind)

Townsville (154,628)

Karratha

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The Rural Medical Generalist Nurses AHWs Allied health NPs, The Generalist Specialist Pharmacists, Physician Assistants, etc

The vacated ground of medical generalism

PUBLIC MATERNITY SERVICES CLOSED SINCE 1995 IN QUEENSLAND

PREDICTORS OF RURAL VOCATIONAL CHOICE IN MEDICINE • Rural origin (and spouse rural origin) • Rurally focused curriculum • Rural clinical exposures as a student • Regional medical program • Regionally-based vocational training

Medical specialists

The ‘GP’??

31

MEDICAL TRAINING PIPELINE?

REGIONAL ACCESS TO SPECIALIST TRAINING • Variable policies and infrastructure for selection between Colleges • Problems with centrally administered ‘merit-based’ systems for regional Australia • Regional planning should be based on community need & training capacity • Little formal role for Universities / RCSs / UDRHs in supporting viability of regionally-based

specialist training

The General Specialist as it applies to the Training & Practice of Surgeons Assoc Professor Phillip Carson Associate Professor of Surgery, Royal Darwin Hospital and Flinders NT Clinical School

Medical school

Public hospital specialist training

Community general practice post

Community specialist practice?

Private hospital?

Hospital-based primary care?

‘Greater Clinical School…’

& teaching ACCHS…

Internationals

Intern & PGY2

SSeerrvviiccee

RReesseeaarrcchh

QQuuaalliittyy

32

THE CURRENT MACRO CLIMATE • Long and accelerating trend towards increased specialisation • Dominant model of delivery of specialist services involves increasing specialist numbers • Royal Australasian College of Surgeons is largely following and supporting this trend

TRAINING PATHWAYS FOR SURGERY • General Surgery (breast , endocrine, upper GI, hepato-billiary, colorectal, oncology, trauma,) • Orthopaedics (Spine, hands, feet, joints, sport) • Otolaryngology/head and neck • Plastic and reconstructive • Vascular • Pediatric • Urology • Cardio-thoracic • Neuro

NEW DIRECTIONS AND NEW PROBLEMS • New SET (surgical education and training) program shortens training at the expense of

generalist skills • There is a current crisis in providing emergency care, especially in the biggest hospitals • The western world is grappling with exponential increases in the cost of health care WHAT THE PEOPLE NEED IS ACCESS TO HIGH QUALITY SPECIALTY SERVICES – NOT NECESSARILY SPECIALISTS • NT, by necessity has developed innovative working models for delivering specialty care • Jon Wardill/ Jim Scattini servicing surgery in Katherine • Visiting neuro-surgeons/ local general surgeons covering head injuries for the Top End

ESSENTIALS OF THE MODEL • Well and broadly trained generalist • Supportive, non-competitive specialist • On going open communication and patient sharing

WIN FOR GENERALIST • Working at capacity • Expanded capacity-in a supported environment • Expanding capacity- development/CME

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WIN FOR SPECIALIST • More interesting and challenging cases • Secure in ongoing care • Decreased workload • Expanded experience by proxy WIN FOR PATIENTS AND THE STATE • Constant local cover • Audit and accountability built in • Attractive careers= enhanced recruitment and retention • Decreased economic and social disruption for patients and employers • Decreased costs

PROVIDING SPECIALTY VS. SPECIALIST SERVICES • Developed by necessity in rural and remote areas • A viable “new” model for tertiary health care delivery in the western world • Cost efficient • Continuous elective and emergency cover in the local area

NT SURGERY’S CONTRIBUTION TO TRAINING GENERALISTS AND APPROPRIATE SPECIALISTS • Participate in national and regional training of specialists (SET) • Expose and train students and junior doctors to the generalist model • Equip GPs with surgical skills • Retrain/orientate appropriate IMG’s • Value add to and broaden recently qualified specialists

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NT TRAINING STRENGTHS • Broad experience • Excellent environment for training those with Rural /remote, emergency, military, cross

cultural and tropical surgical needs • Developing and demonstrating alternative pathways in the delivery of Specialty services

PROVIDING SPECIALIST SERVICES THE SPECIALIST Sees all cases Follow-ups and chronic disease Intermittent service Patients travel to base institution Majority become routine cases PROVIDING SPECIALIST SERVICES THE GENERALIST Sees less Does less De-skilled Emergencies evacuated or done less well No CME, development or audit Non-viable, may leave PROVIDING SPECIALIST SERVICES THE PEOPLE AND THE STATE Some will get better care Some, with complex problems get worse care May be less accessible and intermittent Quality of emergency care decreases Costs- community and personal - increase PROVIDING SPECIALTY SERVICES Tertiary Referral Mutual support and arrangements Joint clinics/procedures/aftercare Shared Care Ongoing links and consultation More discussion, teaching, skill transfer

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The Physician Dr Stephen Brady – Alice Springs Hospital PHYSICIAN TRAINING • 3 years basic physician training • Examination • 3 years advanced training • ASH accredited for 12 months basic training (level 1 hospital) • RDH accredited for 12 months basic training (level 2 hospital) • Advanced training in general medicine, infectious diseases, endocrinology, cardiology,

nephrology (RDH).

PHYSICIAN TRAINING IN ASH • 3, 6 or 12 month hospitals • 3 month rotations from 3 hospitals in 2 states

• Locals, IMGs and trainees from other colleges • Advanced training – the next frontier

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37

NT Adult Physician workforce 2003

PREVALENCE ESTIMATES BY NT REGION, ABORIGINAL POPULATION IN REMOTE AREAS, 2005

0

2

4

6

8

10

12

14

16

Diabete Hypertensi COP IH

Estimated Prevalence

NT - Central NT -Top Australi

Sources: NT Chronic Disease Register, NT Hospital Morbidity data and ABS National Health to 2005 NT Indigenous

38

REMOTE INDIGENOUS COMMUNITIES, 300+ PEOPLE

NT

Alice Springs

Darwin

CanberraAdelaide

Melbourne

Sydney

Brisbane

Perth

Hobart

1,0000

km

discrete Indigenous communities

39

40

41

Physician Education Dr Emma Spencer, Director of Physician Education – Royal Darwin Hospital FACTS • Medical education has improved

o Lets get some historical perspective • Quality training opportunities are inextricably linked to adequate workforce numbers • Administration is a significant diversion of clinicians non-clinical time

o and always will be • ‘Silos’ exist for (some) very good reasons

o natural evolution o Maintenance of professional standards o Practicality of peer review o Process of creating a governance structure

PHYSICIAN TRAINING RDH • Accredited training for 2 years of basic training • Structured program of terms • Grand rounds • Chart review /infectious diseases teaching • JCs (ID gen med pall care endo haem) • RACP

o Curriculum/ Mini CEX • Physicians clinical exams ‘Bulldogs’ • Advanced training in renal IFD haematology (clinical and Lab) general medicine cardiology

palliative care endocrinology ICU • Annual Scientific meeting

PREVOCATIONAL TRAINING • Medical administration • Office of DCT • Articulated philosophy

o –Alice Katherine Tennant Kunnunurra remote area etc to broaden the access

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IMG • Accommodate a small number

o Practical assistance o Cannot completely retrain

• Differing standards of basic medical education • Different cultural values

o Understanding of patient advocacy o Understanding of patient focused care o Understanding that in Australia the boss in not always right

• Need to STRENGTHEN existing structures

PREVOCATIONAL TRAINING AND LEADERSHIP • Gap between reality and expectation

o Requires leadership • Broad and deep exposure

o ‘clinical weight’ o Consequences of shorter work hours

• Process of clinical and personal maturing • Not comfortable • Intellectual independence and self direction

o Without the rigid structure of the eternal childhood of medical school • Protected Teaching Time’

o Not the panacea

PHYSICIANS - WHAT WE NEED(RACP) • Appropriate FTE - 0.3 in addition to clinical FTE

o DPEs and DPPEs Alice and Darwin • Competent administrative support

o Able to facilitate communication between ASH+RDH • Secretarial role PLUS++++ • Support college activities/engage with college • Engage with trainees

o Assist with college processes • Run scientific meeting • IT support/advertising/raising profile • Advocacy college training

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PHYSICIANS - WHAT WE NEED(HOSPITAL BASED) • Competent hospital/departmental administrative support

o Fulfill basic administrative functions o advertising o Registrar recruitment processes o Setting up interview times…

• IT support/facilitating teaching sessions • Positive engagement re prevocational access to medical terms

DEVELOPMENT • Allow flexibility

o Practical administrative SUPPORT!!! • Support clinicians

o With time and money o They do the teaching (usually for free and usually in their own time) o Understand the value of bedside teaching

• Strengthen the basic tenants of medical education in Australia o Patient advocacy o Patient focused care o Clinical governance

• Don’t reinvent the wheel

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Continuing Professional Development Dr Charles Kilburn

REGULATORY REQUIREMENTS OF CPD • Model of medical regulation

o 19 th century o Initial registration requirements o Annual fee

• Inadequate for 21st century Continuing Medical Education Under the new Medical Practice Act 2004 s38 (2) (b) a registered person must in each calendar year on a date fixed by the Board pay an annual practice fee fixed under this Act and complete a renewal form approved by the Board, containing all information requested including the undertaking of any course of continuing medical education (CME) by the person during the preceding year. The 2005–2006 renewal form will require applicants to complete this section. Please note registration will not be refused in the absence of any evidence of continuing medical education; however, practitioners should note that this will be subject to future Board determination following further discussion with the relevant parties.

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REGULATORY REQUIREMENTS OF CPD

No requirement for CPD

MEDICAL BOARD OF THE AUSTRALIAN CAPITAL TERRITORY Are you able to provide evidence of recency of medical practice in the past five years? Yes No If you practise in a private capacity, are you currently covered by a policy of medical indemnity insurance at an appropriate level? Yes No Are you able to demonstrate ongoing professional development? If yes and you are participating in a program, list the title of the program: Provided by: Yes No No clear requirements for recency or CPD on application forms

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The College Council has mandated compulsory participation by Fellows in the MOPS program. Fellowship is not a time limited qualification therefore the Council does not have the right to take the Fellowship away from Fellows not participating in the program. Certain medical boards currently require that enrolment in a MOPS program be confirmed when seeking medical registration. It is expected that all medical boards will introduce this requirement in the near future.

•

Participation Only registered medical practitioners are eligible to enroll in the ANZCA CPD Program. Enrolment is not necessary for Fellows and there is no fee. Fellows who wish to participate in another CPD program in lieu of the ANZCA program need to contact the College for guidance. Anaesthetists who are not Fellows of ANZCA are welcome to participate, for which a fee will be payable. Although at present not all jurisdictions require participation in CPD for Recertification, the forthcoming Australian single national registration to be implemented by the Council of Australian Governments (COAG), heralds mandatory participation

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The Maintenance of Professional Standards (MOPS) Program was implemented in 1994 as a strategy to promote continual professional development. The MOPS program provides Fellows of the College with a way of formally documenting their participation in a range of continuing education and quality assurance activities. Voluntary, not linked to fellowship or re-certification

Royal Australasian College of Surgeons The CPD Program is conducted over a triennium, currently 2007–2009. All active Fellows in medical, surgical or medico legal practice have a requirement to participate. The CPD Program provides flexible requirements according to type of surgical practice. Voluntary, not linked to fellowship or re-certification

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• The RANZCOG continuing professional development (CPD) program is designed to

facilitate three endeavours: training, continuing education and review. • In 1986, RANZCOG Fellowship became linked to a mandatory program of continuing

education and recertification. The New Three year Continuing Education Program was approved by Fellows of the College on 3 March 1999. Fellows must obtain 150 points over the three-year cycle of this program.

• Inconsistent from jurisdiction to jurisdiction • Inconsistent between Colleges • No clear responsibility between Boards, Colleges and employers • Inadequate • National consistency required by 2010

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Australian Indigenous Doctors Dr Latisha Petterson WHO WE ARE • Over 120 Indigenous medical graduates (doctors) working across the country • Over 120 Indigenous medical students studying in medical schools across Australia We work as • Medical Officers • General Practitioners • Surgeons • Cardiologists • Obstetricians and Gynaecologists • Physicians • Psychiatrists • Public Health Physicians • Medical Educationalists • Researchers

WHAT WE DO - 1 AIDA advocates for improvements in Indigenous health in Australia and encourages Aboriginal and Torres Strait Islander people to work in medicine by supporting Indigenous students and doctors. AIDA incorporates the philosophy that Life is Health is Life in its policy and advocacy work, encouraging equitable health and life outcomes for Aboriginal and Torres Strait Islander people throughout leadership and in the spirit of cultural integrity. AIDA is a not-for-profit, non-government organisation dedicated to the pursuit of leadership, partnership & scholarship in Aboriginal and Torres Strait Islander health, education and workforce.

WHAT WE DO - 2 AIDA works with governments at all levels, health organisations and medical schools to promote Indigenous health and to provide policy advice to:

• Department of Health and Ageing • Medical Deans Australia and New Zealand • National Aboriginal and Torres Strait Islander Health Council (NATSIHC) • Australian Medical Workforce Advisory Committee (AMWAC) • Aboriginal and Torres Strait Islander Health Workforce Working Group (ATSIHWWG) • General Practice Education and Training Aboriginal and Torres Strait Islander Reference

and Consultative Groups (GPET)

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• National Aboriginal and Torres Strait Islander Health Council (NATSIHC) • Royal Australasian College of Physicians Aboriginal and Torres Strait Islander Health

Advisory Committee (RACP) • Royal Australian College of General Practitioners Joint Consultative Committee for

Aboriginal and Torres Strait Islander Health (RACGP) and others

WHAT WE DO - 3 AIDA provides support to our members through

• Mentoring • Representation on advisory and selection committees e.g. – Puggy Hunter Memorial

Scholarship Scheme • Advocating for better recruitment, support and retention of Aboriginal and Torres Strait

Islander students and staff • Advocating for institutional change on Indigenous health issues

WHAT WE BRING AS INDIGENOUS DOCTORS

• Spiritual, Cultural, Emotional and Physical understanding • Holistic approach to health • Tradition of healing • Trust, Respect and Connection to Community

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Acute Care Division Mr Peter Campos – Assistant Secretary, Dept of Health & Community Services

HISTORICAL ARRANGEMENTS

• Flinders University – NT Clinical School • Supports teaching in the NT Hospital Network

BENEFITS

• Contribute to national effort • Training our “own” • Specialist training has increased at Royal Darwin Hospital and Alice Springs Hospital

CHALLENGES

• Recruitment and retention of medical staff o Nationally o Remote areas

FOR THE FUTURE

• Enhance focus on Teaching, Research & Clinical Practice • Demand for medical staff across Australia over the next 20 years • Encourage generalist rather than sub specialties except where critical mass exists in the

NT • How to include International Medical Graduates • Sustainability of services • Establish NT wide hospital network rotations and links into community training • Establish medical training links with:

o Kimberley and Top End Queensland o East Timor and Indonesia

NTG/BIITE PARTNERSHIP AGREEMENT Schedule 6 Early Childhood Schedule Leaders:

• •Lyn Fasoli (BIITE • Jenny Cleary (NTG)

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Health Services Division Ms Jenny Cleary Assistant Secretary, Dept of Health & Community Services OVERVIEW OF HEALTH SERVICES DIVISION NT’s unusual PHC sector:

• Health Services Division as direct service provider • Long standing participation in medical training (preceding NT-based med trng/support

agencies)

• Community and public health services: o Education, prevention, early intervention, assessment, treatment and support

services

• Program areas: o Health Development/Oral Health, Remote Health, Community Health (Urban),

Environmental Health, Disease Control

• 840 Staff (approx), includes 40 Doctors

REVIEW INDICATES • Complex medical training environment (37 direct stakeholders) • Important to develop the NT medical workforce locally • Critical and urgent need to streamline the current mix of arrangements • Acknowledge recent work:

o Amalgamation of TEDGP, CADPHC and GPPHCNT o Collaboration between DHCS / TEDGP on placement of medical students o Education stakeholders contributing to planning for the Palmerston Superclinic o Strong links between Rural Clinical School and NTGPE for coordination of student

placements o NTGPE and DHCS collaborating on clinical supervision

FUTURE MEDICAL WORKFORCE NEEDS

• Community-based practitioners: o interest in Public Health issues and practices o flexibility and innovation o willingness to explore new models through team-based practice o willingness to work within clearly defined protocols (CARPA); and willingness to

share their expertise • Hospital-based doctors:

o awareness of socio-economic-cultural history of their clients o awareness of the realities and challenges of

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delivering services in NT urban and remote communities; and o preparedness to support seamless client-focused services beyond the hospital

NEED FOR COORDINATION

• What do we mean by coordination? o Planning student numbers by site and supervisor o Balancing undergraduate and post-graduate placements

• Positive client balance of registrars o Coordination of learning outcomes o Coordination of communication with medical schools/ providers

• Reporting demands • Student support

o Other health professional training

• How? o Training institutions in competition with one another

CURRENT ENVIRONMENT

• Public health physicians- critical leaders across NT health system • Inter-dependence, inter-relationships in service provision (benefits and challenges) • Training and education delivered locally:

o challenging and complex o limitations result in diminishing capacity; opportunity costs of diverting existing

specialist services

ISSUES FOR RESOLUTION • Health centers are not ‘swamped’ with students from various providers • Aims and objectives of the placement are understood by the placement supervisor • Effective and appropriate supervision • Student housing and travel support • Increasing rigor and cost of accreditation • Coordinated, innovative support for students and registrars in our urban community-based

settings

CONCLUSION • DHCS is committed to providing safe, effective, enjoyable, memorable placements for

medical students in urban and remote settings • Improved planning, coordination and re-sourcing needs to be from a national perspective • Optimism re common ground, shared goals